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Introduction

Telemedicine provides the opportunity of delivering health care at a distance, and reduces the need for a face-to-face interaction. It is often conducted by videoconferencing, which permits a high-quality interaction between the parties concerned, but demands relatively expensive equipment and high bandwidth communications. In the context of developing countries, there has been little use of videoconferencing, for the obvious reason of cost. Most of the videoconferencing work that has been conducted has been for the purposes of education.^1–3

Although there has been little use of real-time telemedicine, much useful clinical work has been performed in developing countries using store-and-forward techniques, which are less expensive of infrastructure and easier to organize because the interaction between the parties concerned is asynchronous. The two main methods of store-and-forward telemedicine are based on use of web messaging or on email.

Web telemedicine

In web-based telemedicine (for clinical purposes), the referring doctor connects to the Internet and completes a web-based proforma that stores the patient details and any associated images on a remote server. This information is reviewed by a specialist at some later time, and appropriate diagnostic and management advice is provided. The specialist’s reply is stored on the web server, from where the referring doctor can access it. To ensure patient confidentiality, the information comprising the telemedicine interaction is normally stored on a secure server and protected by passwords.

The US military had considerable experience with web-based teledermatology in the late 1990s in Europe.⁴ They have also operated a web-based teleconsulting system from the main US Army hospital in Hawaii that supports referrers in hospitals (mainly military hospitals) on US-associated Pacific islands.^5,6 Further details are provided in Chapter 15.

Finally, a software package called iPath was developed for telepathology case conferences, and several tens of thousands of case conferences have now been conducted – technically by a number of different organizations who all use the same software. The use of this software for general clinical work (i.e. non-pathology) is more recent.⁷

Email telemedicine

One drawback of web-based telemedicine is that in developing countries there are still places where Internet connections are expensive, and therefore web access in particular is restricted. Almost all health care facilities have, or could have, telephone access to the Internet, so this represents the lowest-cost communications medium for telemedicine.

In email-based telemedicine, the telephone network is used to transmit email messages via a dial-up connection to an Internet service provider (ISP). The referring doctor records the relevant patient information in the body of the email message, and images of patients, or X-ray films, can be attached if required. The specialist can reply by email at a convenient time.

Email telemedicine is cheap, but it has some drawbacks:

• On any significant scale, i.e. with multiple referring doctors and multiple specialists, managing the traffic is a demanding and labour-intensive task. Messages may then fail to be replied to.
  
  
• Information sent in an ordinary email message is not secure. Although the case details can be anonymized to protect patient confidentiality, this depends on the message sender, and is often difficult to enforce in practice.
  
  
• Because the referring doctor enters free text, it is much harder to ensure that all relevant patient history details are collected.
  
  
• Any system of communication that employs email will sooner or later be bombarded with spam or nuisance messages.

Two long-running examples of the use of email for low-cost telemedicine are the work of the Swinfen Charitable Trust and of Partners Telemedicine.

Swinfen Charitable Trust

The British military first used email telemedicine successfully in Bosnia.^8,9 In the 1990s, Lieutenant Colonel David Vassallo, together with Surgeon Commander Peter Buxton and Wing Commander John Kilbey, established a technique in which a digital camera was used to capture images, which were then downloaded to a laptop computer. The images were attached to an email message and then sent to the Royal Hospital Haslar in the UK for evaluation and advice. A commercial INMARSAT satellite telephone link was employed for communication in the field. The system proved useful when a Czech Forces Helicopter crashed in Bosnia in January 1998, severely injuring five crew members.¹⁰ David Vassallo and Peter Buxton generously shared information about the system with Lord and Lady Swinfen, enabling them to start a pilot project at the Centre for Rehabilitation of the Paralysed in Bangladesh. This began in 1999 (see below).

Partners Telemedicine

Since 2001, email consultations have been used to support health workers at a rural clinic in northern Cambodia. The email advice comes from specialists at a tertiary hospital in Phnom Penh and from the Massachusetts General Hospital in Boston. In 2003, a second site at a small hospital in northern Cambodia began referring cases.¹¹ Further details are provided in Chapter 13.

Start of the network, 1999

The Swinfen Charitable Trust was established in 1998 to assist poor, sick and disabled people in the developing world. It is an apolitical, non-religious organization, registered as a charity in the UK. The Trustees decided to provide medical specialist advice, free of charge, to assist doctors caring for poor patients, as they were unaware of any such service at the time. In July 1999, an email telemedicine link was established for a hospital in Bangladesh, the Centre for the Rehabilitation of the Paralysed (CRP). The CRP, which is located near Dhaka, is a specialist spinal injury unit that services a large region of South-East Asia. Email referrals thus concentrated mainly on orthopaedics and neurology problems.

The email referrals were received by the administrators of the charity and sent on for reply to members of a small panel of medical specialists who had kindly offered to provide advice free of charge. This was a pilot study and, after a year of email referrals, a paper was published demonstrating that the system worked satisfactorily, and provided patient benefit and medical education to the referring doctors.¹²

The CRP has continued to refer cases to the Swinfen Charitable Trust network. At the time of writing, 182 cases have been referred in 10 years (Figure 19.1).

Figure 19.1 CRP referrals, July 1999–June 2008 inclusive

Growth of the network, 1999–2004

Although the initial telemedicine link to the CRP was a pilot study, word of its value quickly spread and, by the end of its first year of operation, two other telemedicine links had been requested. These were established at hospitals in Kathmandu, Nepal and the Solomon Islands. From then on, the numbers of links requested and set up grew rapidly.¹³

Manual management of the messages by the charity (e.g. forwarding a new referral message to an appropriate specialist, forwarding the resulting reply to the referrer and dealing with any subsequent dialogue) was satisfactory for a single hospital, but rapidly became unmanageable as the number of hospitals and the email workload increased. It was also difficult to extract statistics about the operation of the network, since plain email provides a poor archive, because it is ‘unthreaded’. An automatic email message-handling system was therefore developed by the Centre for Online Health at the University of Queensland.¹⁴ This came into operation in 2002, and solved several of the problems associated with manual message management.

From July 1999 to March 2003, the network grew to 17 hospitals. As well as more referring hospitals, more volunteer specialists were recruited.¹³ Many were from the UK and Australia. The Swinfen Charitable Trust continues to be indebted to the consultant specialists and others who contribute voluntarily to the operation of the network.

Iraq and the Middle East

The Iraq war began in March 2003 with the invasion of Iraq by a multinational coalition of troops from the USA and the UK, supported by smaller contingents from Australia, Poland and other nations. In 2004, the administrators of the Swinfen Charitable Trust visited Basra as part of a British medical mission. During that visit, contact was made with doctors from several Iraqi hospitals, who subsequently joined the email referral network (Figure 19.2). This led to a jump in the number of cases referred from Iraq in particular, and from other parts of the Middle East generally (Table 19.1).

A review conducted in 2007 showed that there was evidence of improved management of cases as a result of email telemedicine.¹⁵ The review also showed that the case mix from countries of the Middle East was different from that from the rest of the world (although, technically, the difference was not significant at p < 0.05). There was more obstetrics and gynaecology, and less medicine and radiology (Table 19.2). Despite the majority of Middle Eastern cases being referred from Iraq, relatively few were the direct result of conflict, and there were fewer trauma and fracture cases than from the rest of the world. There were also comparatively fewer referrals in infectious and tropical diseases. The relative absence of trauma cases can perhaps be explained by well-developed local expertise in trauma care. This local expertise was honed during the Iraq conflict, during the eight years of the Iraq–Iran war and during the internal troubles of the Saddam Hussein regime.

The U21 consortium

The Universitas 21 (U21) is an international grouping of 21 leading research-intensive universities in 13 countries from around the world. The purpose of the consortium is to facilitate collaboration between the member universities and to create opportunities for them on a scale that none of them could achieve by operating independently or through traditional bilateral alliances. The U21 consortium has a strong health sciences group, led by the deans of medicine, nursing, dentistry and rehabilitation sciences of the various member universities.

Figure 19.2 First-referral dates for Iraqi hospitals (n = 49)

At the suggestion of the health sciences group, a Memorandum of Understanding was signed between the U21 consortium and the Swinfen Charitable Trust in 2006. The main objective of the Memorandum was to advance the aims of the Swinfen Charitable Trust by drawing on U21 resources, such as consultants, medical students, nursing/allied health students and other support.

The first pilot project involved U21 universities providing support to an under-served health facility in a developing country.¹⁶ The initial aim was to assist local doctors via information and communications technology – telemedicine – and to involve U21 medical students on elective placements. As well as establishing low-cost telemedicine networks in developing countries, a long-term aim was to gather data about their effectiveness.

The project began in mid-2005. In the first two years, a total of eight medical students from four U21 universities spent their electives at hospitals in Pakistan, Papua New Guinea and Sri Lanka. Most electives lasted about four weeks. Most of the students were in their final year.

A total of 49 cases were referred either directly by the students or indirectly by the medical staff with whom they worked (i.e. after the students had left).¹⁷ The students were responsible for a total of 49 e-referrals, which resulted in 67 queries in a wide range of specialties. The median response time was 20 hours (interquartile range 5–85). Follow-up data were obtained in 14 of the 30 cases from one hospital (47%). The major categories of the 67 queries were internal medicine, paediatrics and surgery, and in very similar proportions to the 785 queries managed by the Swinfen Charitable Trust over the same period.

Before the project began, some initial concerns were expressed by certain consortium members about possible medicolegal risks, and whether students would feel superfluous in a local health care environment. Happily, none of these matters turned out to be real problems. Indeed, the students reported that the U21 project gave a purpose to their placement. One student expressed it as follows: ‘often students don’t always have a “role” other than to sometimes feel as though you are hanging around as the silent observer. This way you could feel as though you were contributing.’ ¹⁷

The presence of a medical student facilitated e-referrals by relieving the pressure on the local doctor to undertake the necessary clerical and technical work. The students reported a rewarding elective experience, which appears to have the potential to increase the ease with which heavily burdened medical staff in developing countries can make use of e-referrals.

The future

Over the first 10 years of its operation, the Trust has established telemedicine links for 135 hospitals/clinics in 34 countries and dealt with over 1700 referrals (Figure 19.3). How do we rate the success of this international e-referral network after 10 years of operation? There are many indicators that could be employed to measure success in telemedicine.¹⁸ These include longevity and clinical outcomes.

If longevity is the criterion, then the Swinfen Charitable Trust is doing pretty well for a telehealth operation, many of which – as has been observed elsewhere – blossom on a wave of initial enthusiasm and then wither when the seed funding runs out. However, if clinical outcome is the criterion, then the operation represents a failure at present, because there are no formal follow-up data. This is due to the fact that the majority of patients, once treated, return home, and do not come back to the hospital for follow-up appointments. This occurs because of travel distance, time and cost, including loss of income. However, one of the aims of the U21 involvement is to obtain follow-up information, and the medical students in Papua New Guinea have begun providing it (and it is showing useful outcomes).¹⁷

Figure 19.3 Swinfen Charitable Trust Network (July 2008)

It is also worth pointing out that the Swinfen Charitable Trust must be providing a clinically useful service to the referrer doctors, or they would not continue to use it. This was confirmed in a survey of referrers conducted in 2004.¹⁹

Ultimately, sustainability probably depends on scaling up the size of the present operation, which in turn requires the real costs to be met, i.e. when operating on a large scale, depending only on volunteers would be difficult. This would mean paying for the medical time involved in answering the referrals, for example, which in turn would require an income stream. Charities may have difficulty in operating in this environment, i.e. where there are pressures to increase in size to make things financially sustainable, with simultaneous counter-pressures to reduce in size because things depend on volunteers.

The work of the Swinfen Charitable Trust (and others) demonstrates that low-cost telemedicine in the developing world is feasible, clinically useful, scalable and apparently sustainable. However, telemedicine is not yet being used on a significant scale. What then is the right strategy? The sensible approach appears to be to build intra-country telemedicine networks as soon as practicable. That is, we need telemedicine networks that rely largely on within-country resources. Such telemedicine networks might need to begin with support from outside the country, but they should become independent of outside resources as quickly as possible.²⁰

Further reading

Swinfen Charitable Trust. Available at: www.swinfencharitabletrust.org.

Universitas 21 Health Sciences Group. Available at: www.u21health.org/index.html.

References

¹ Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing medical education and tele-consultations over the Internet in French-speaking Africa. Int J Med Inform 2007; 76: 351–6.

² Vincent DS, Berg BW, Hudson DA, Chitpatima ST. International medical education between Hawaii and Thailand over Internet2. J Telemed Telecare 2003; 9(Suppl 2): 71–2.

³ Ozuah PO, Reznik M. The role of telemedicine in the care of children in under-served communities. J Telemed Telecare 2004; 10(Suppl 1): 78–80.

⁴ Pak HS, Welch M, Poropatich R. Web-based teledermatology consult system: preliminary results from the first 100 cases. Stud Health Technol Inform 1999; 64: 179–84.

⁵ Callahan CW, Malone F, Estroff D, Person DA. Effectiveness of an Internet-based store-and-forward telemedicine system for pediatric subspecialty consultation. Arch Pediatr Adolesc Med 2005; 159: 389–93.

⁶ Person DA. Pacific Island Health Care Project: early experiences with a Web-based consultation and referral network. Pac Health Dialog 2000; 7: 29–35.

⁷ Brauchli K, Oberli H, Hurwitz N et al. Diagnostic telepathology: long-term experience of a single institution. Virchows Arch 2004; 444: 403–9.

⁸ Vassallo DJ, Buxton PJ, Kilbey JH, Trasler M. The first telemedicine link for the British Forces. J R Army Med Corps 1998; 144: 125–30.

⁹ Vassallo DJ, Buxton PJ, Kilbey JH. Telemedicine made easy – the British way. Mil Med 1998; 163: iii.

¹⁰ Vassallo DJ, Klezl Z, Sargeant ID, Cyprich J, Fousek J. British–Czech co-operation in a mass casualty incident, Sipovo. From aeromedical evacuation from Bosnia to discharge from Central Military Hospital, Prague. J R Army Med Corps 1999; 145: 7–12.

¹¹ Heinzelmann PJ, Jacques G, Kvedar JC. Telemedicine by email in remote Cambodia. J Telemed Tele-care 2005; 11(Suppl 2): 44–7.

¹² Vassallo DJ, Hoque F, Roberts MF et al. An evaluation of the first year’s experience with a low-cost tele-medicine link in Bangladesh. J Telemed Telecare 2001; 7: 125–38.

¹³ Wootton R, Youngberry K, Swinfen R, Swinfen P. Referral patterns in a global store-and-forward tele-medicine system. J Telemed Telecare 2005; 11(Suppl 2): 100–3.

¹⁴ Wootton R. Design and implementation of an automatic message-routing system for low-cost telemedicine. J Telemed Telecare 2003; 9(Suppl 1): 44–7.

¹⁵ Patterson V, Swinfen P, Swinfen R et al. Supporting hospital doctors in the Middle East by email telemedicine: something the industrialized world can do to help. J Med Internet Res 2007; 9: e30.

¹⁶ Wootton R, Jebamani LS, Dow SA. E-health and the Universitas 21 organization: 2. Telemedicine and underserved populations. J Telemed Telecare 2005; 11: 221–4.

¹⁷ Wootton R, Swinfen PA, Swinfen R et al. Medical students represent a valuable resource in facilitating telehealth for the underserved. J Telemed Telecare 2007; 13(Suppl 3): 92–7.

¹⁸ Wootton R, Hebert MA. What constitutes success in telehealth? J Telemed Telecare 2001; 7(Suppl 2): 3–7.

¹⁹ Wootton R, Youngberry K, Swinfen P, Swinfen R. Prospective case review of a global e-health system for doctors in developing countries. J Telemed Telecare 2004; 10(Suppl 1): 94–6.

²⁰ Wootton R. Telemedicine support for the developing world. J Telemed Telecare 2008; 14: 109–14.

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